Family Practice
© Oxford University Press 2001
Vol. 18, No. 2
Printed in Great Britain
Antibiotic prescribing in acute infections of the
nose or sinuses: a matter of personal habit?
An I De Sutter, Marc J De Meyere, Jan M De Maeseneer and
Wim P Peersmana
De Sutter AI, De Meyere MJ, De Maeseneer JM and Peersman WP. Antibiotic prescribing in
acute infections of the nose or sinuses: a matter of personal habit? Family Practice 2001; 18:
209–213.
Background. A proper understanding of how and why GPs prescribe antibiotics in general
practice is essential for the design of strategies aimed at making prescribing more rational.
Objective. The intention of this study is to contribute to such understanding by investigating
which elements are important in the GP’s decision to prescribe antibiotics for patients with acute
infectious complaints of the nose and/or sinuses.
Methods. During their training in general practice, students observed the following elements
while attending encounters between their trainer-GP and patients with a runny nose, blocked
nose or cough: patient characteristics, contact characteristics, signs and symptoms, diagnosis
and prescriptions. Information on practice characteristics and characteristics of the trainer-GP
were collected. Data were analysed using multiple logistic regression and multiple linear
regression.
Results. A total of 722 cases were analysed with the following results: the best independent
predictor of an antibiotic prescription is the individual antibiotic prescribing rate (IAPR), which
expresses the personal habit of the GP in prescribing antibiotics [adjusted odds ratio (OR) 5.27,
95% confidence interval (CI) 3.22–8.62]. Others are the diagnostic labels ‘sinusitis’ (adjusted OR
2.80, 95% CI 1.2–6.49) and ‘flu-like syndrome’ (adjusted OR 0.08, 95% CI 0.01–0.45), and the sign
‘sinus tenderness’ (adjusted OR 4.37, CI 2.15–8.89). The antibiotic prescribing behaviour
intensifies with an increasing tendency to prescribe medication in general (β = 0.46, P , 0.00) and
with an increasing defensive attitude (β = 0.22, P , 0.05).
Conclusions. Whether or not a patient with an acute infection of the nose and/or sinuses will
be handed an antibiotic prescription seems to depend more on the attending doctor’s prescribing behaviour than on the clinical picture. Further qualitative research into attitudes which may
be related to a high tendency to prescribe antibiotics consequently is of the utmost importance.
Keywords. Antibiotic prescribing, family practice, physician’s practice patterns, prescribing
behaviour, upper respiratory tract infections.
the disease to run its natural course is probably the best
approach:1 clinical trials show that benefit from antibiotics is minimal, while other opposing arguments
include adverse side effects, development of bacterial
resistance and the financial cost to the patient and
society.
Strategies to change prescribing behaviour will only
be successful when they are based on a proper understanding of how and why GPs prescribe antibiotics.
In this study, our aim was to contribute to this understanding by exploring to what extent various factors—
such as the diagnostic label, the patient’s signs or symptoms
and contextual factors—are important in the GP’s
Introduction
In general practice, acute upper respiratory tract
infections are one of the main reasons for prescribing
antibiotics. However, evidence is mounting that in nonimmune-compromised patients, watchful waiting for
Received 22 February 2000; Revised 12 July 2000; Accepted
30 October 2000.
Department of General Practice and Primary Health Care, and
aDepartment of Population Studies and Social Science
Research Methods, University of Gent, De Pintelaan, 185,
B-9000 Gent, Belgium.
209
210
Family Practice—an international journal
decision to prescribe antibiotics for patients with acute
infectious complaints of the nose or sinuses.
Methods
In 1996, during three periods of 1–4 days, students of
the medical school of Gent (Belgium) undergoing
elective vocational training in general practice observed
the encounters of their trainer-GP with patients having
one of the following symptoms: runny nose, blocked nose
and/or cough. They registered patient characteristics,
signs and symptoms, diagnostic label and treatment
(Tables 1 and 2). Data on the observed GPs were
also collected (Table 1). The ‘defensive attitude score’
expresses the GP’s ‘risk-avoiding attitude’ and was
measured using a validated questionnaire: the higher the
score, the more the GP will always prefer the certain to
the uncertain.2 The individual antibiotic prescribing rate
(IAPR) measures the tendency to prescribe antibiotics
and was calculated by dividing the number of encounters
with an antibiotic prescription by the total number of
encounters registered with this GP. The tendency to
prescribe in general is the mean number of medications
prescribed per registered contact.
Analysis
Data were entered in SPSS 7.5 for Windows. Statistics
used were odds ratios (ORs), Pearson’s correlation
coefficients, Student’s t-test, multiple linear regression
and multiple logistic regression.
Results
Eighty GPs participated. Four were women, 72 had more
than 10 years’ experience in practice and 47 worked in
a single-handed practice. A total of 722 out of 1052
registered encounters were analysed; all patients with a
normal clinical pulmonary examination and at least one
symptom related to the nose or sinuses were included.
The patient’s mean age was 32 years, and 55% were
women (Table1).
The best independent predictor of an antibiotic
prescription was the IAPR of the prescribing GP. Others
were the diagnostic labels ‘sinusitis’ and ‘flu-like
syndrome’, and the sign ‘sinus tenderness’ (Table 2). The
IAPR of the GPs varied extensively from 0 to 100%:
some prescribed no antibiotics at all; others prescribed
them in every encounter (Table 1). The mix of diagnoses
allocated by doctors with a high IAPR was not significantly different from that of those with a low IAPR (data
not in table). The IAPR intensifies with an increasing
tendency to prescribe medication in general and with an
increasing defensive attitude (Table 1).
Discussion
Our main finding is that patients with complaints of
the nose or sinuses are prescribed antibiotics primarily
because they consult a GP who usually prescribes antibiotics for this disease, and not so much because they are
suffering from certain signs or symptoms or because a
particular diagnosis has been made. The results show that
GPs have very divergent antibiotic prescribing behaviours and that precisely this personal tendency is the best
predictor—better than diagnosis or signs and symptoms
—of whether or not a patient will be prescribed an antibiotic. Several studies3,6–9 have already drawn attention
to the importance of contextual factors in prescribing
but, to our knowledge, this is the first time that it has
been shown, in quantitative terms, that non-biomedical
factors can be even more important than clinical facts in
antibiotic prescribing.
Also significant, but to a lesser extent, are the ‘flu-like
syndrome’ label associated with fewer antibiotic
prescriptions and the ‘sinusitis’ label associated with
more, which confirms previous research.3 However, frequencies of various diagnostic labels are not significantly
different between low and high prescribers, which rather
contradicts Howie’s statement that diagnoses are chosen
as a justification for treatment.4 Finally, ‘tenderness of
the sinuses’, an important sign for GPs when making
the diagnosis ‘sinusitis’,5 is apparently an indication of
sinus involvement and thus a reason to prescribe more
antibiotics in other diagnoses too.
With regard to the method, using students as
observers made it possible to collect data on real patient
encounters, thus avoiding possible bias by self-reporting
or reporting on simulated case histories. Nonetheless, all
participating GPs inevitably were trainers associated
with the university and, moreover, well aware of being
observed. However, this probably made their antibiotic
prescribing more uniform and ‘by the book’ and actually
makes the variations in IAPR even more remarkable.
The students, moreover, recorded only facts. The influence of other factors known to be important, such as
patients’ expectations,6 the doctor–patient relationship7,8
and psychosocial background features9 were not investigated. It is unlikely, however, that these factors would
increase the importance of clinical facts in prescribing
antibiotics.
In our data, we found two indications why some
GPs prescribe more antibiotics than others. First, high
prescribers are GPs who prescribe a lot of medication
in general. They prescribe antibiotics in addition to
symptomatic therapy and not as a substitute for it.
Secondly, high prescribers have a ‘defensive attitude’,
which means that they are unwilling to take risks and
have problems in coping with uncertainty. Both of these
findings are in line with previous research.2,3,10 Interestingly, research also shows that defensiveness is not
merely a personal characteristic of GPs but can be
211
Antibiotics for nose and sinus infections
TABLE 1
Relationships between antibiotic prescribing and patient, encounter and doctor characteristics
Patient and encounter characteristics and correlations with number of antibiotic prescriptions
Patients
No. (%)
with antibiotic
Gender
OR (95% CI)
prescription
Female
Male
140/385 (36)
110/321 (34)
1.1 (0.79–1.51)
Chronic respiratory disease
Yes
No
13/28 (46)
245/694 (35)
1.59 (0.51–4.88)
Age
,10
10–65
.65
53/131 (40)
173/491 (35)
11/41 (27)
Home visit
Yes
No
67/179 (37)
173/495 (35)
1.11 (0.77–1.61)
Follow-up encounter
Yes
No
53/149 (35)
193/539 (36)
0.99 (0.67–1.47)
Chi square
P = 0.254
Encounter
OR
Doctors’ characteristics and correlation with IAPRa
Pearson’s R
Mean (SD)
IAPRb
0.39 (0.32)
Defensive scoreb
Tendency to prescribe in
P-value
16 (3.9)
generalb
Tendency to make home visitsb
0.299
0.016
1.66 (0.62)
0.451
0.000
0.26 (0.23)
0.084
0.49
–0.028
0.83
Mean difference in IAPR
P-value
n (%)
No. of years in practice
n = 74
,5
5–10
11–20
21–30
.30
0
8 (11)
37 (50)
24 (32)
5 (7)
Comparison of IAPR between different groups of GPs: Student t-test
n (%)
University of graduation
Ghent
Other
60 (75)
20 (25)
0.009
0.93
Practice type
Solo
Group
47 (62)
29 (38)
0.038
0.63
Gender
Male
Female
76 (95)
4 (5)
0.18
0.20
Multiple linear regression analysis of IAPR on tendency to prescribe and score of defensive attitude
B
Tendency to prescribe
Score defensive attitude
28.37
1.62
95% CI
14.91–41.82
0.001–3.246
β
P-value
R2
0.458
,0.00
0.292
0.217
,1.05
a Number of encounters with antibiotic prescription registered/total number of encounters registered with GP; b calculated only for GPs with a
minimum of five encounters registered (n = 69).
212
TABLE 2
Family Practice—an international journal
Variables associated with prescribing an antibiotic to a patient with acute infectious complaints of the nose and/or sinuses: biavariate and
multivariate analysisa
No. with ab prescription (%)
Category of IAPRc
1., 0, mean of all GPs
Cat = 1
193/329 (59)
Diagnostic label
Cat = 0
65/393 (17)
Crude ORs
(95% CI)b
Adjusted ORs
(95% CI)
7.16 (5–10.27)
5.27 (3.22–8.61)
With this label
With other label
Sinusitis
29/55 (53)
212/632 (34)
2.21 (1.23–3.99)
2.8 (1.2–6.49)
Pharyngitis
24/49 (49)
217/638 (34)
1.86 (1–3.47)
1.97 (0.85–4.57)
Rhinosinusitis
36/93 (39)
205/594 (35)
1.20 (0.75–1.92)
1.15 (0.58–2.29)
Rhinopharyngitis
44/118 (37)
197/569 (35)
1.12 (0.73–1.73)
0.96 (0.46–1.97)
Flu-like syndrome
22/114 (19)
219/573 (38)
0.39 (0.23–0.65)
0.08 (0.01–0.45)
Rhinitis
24/134 (18)
217/553 (39)
0.34 (0.20–0.55)
0.60 (0.27–1.32)
Present
Absent
58/97 (60)
200/625 (32)
3.16 (1.99–5.02)
4.37 (2.15–8.89)
Symptoms and signs
Sinus tenderness
Purulent secretion on tonsils
d
9/15 (60)
249/707 (35)
2.76 (0.89–8.82)
3.38 (0.9–12.73)
Post-nasal drip
20/44 (45)
238/678 (35)
1.54 (0.80–2.96)
2.15 (0.97–4.79)
Purulent rhinorroea
41/78 (60)
104/334 (31)
2.45 (1.44–4.17)
1.96 (0.96–3.99)
Swelling of submandibular glands
55/122 (54)
203/600 (34)
1.61 (1.06–2.43)
1.48 (0.88–2.47)
Productive cough
122/269 (45)
136/453 (30)
1.93 (1.40–2.68)
1.37 (0.85–2.23)
Sore throat
111/280 (40)
147/442 (33)
1.32 (0.95–1.82)
1.35 (0.87–2.08)
Red inflammation of throat
127/326 (39)
131/396 (36)
1.29 (0.94–1.77)
1.29 (0.83–2)
Elevated temperature
85/224 (38)
173/498 (35)
1.15 (0.82–1.61)
1.15 (0.75–1.74)
General symptoms
200/563 (36)
58/159 (36)
0.96 (0.65–1.41)
1.03 (0.63–1.69)
Runny nose or stuffy nose
188/549 (32)
70/173 (40)
0.77 (0.53–1.11)
1 (0.62–1.58)
Sinus pain in history
48/113 (42)
210/609 (34)
1.40 (0.91–2.15)
0.93 (0.5–1.73)
127/353 (36)
131/396 (36)
1.02 (0.74–1.40)
0.88 (0.58–1.35)
Swelling nasal mucosa (rhinoscopia)
75/231 (32)
183/491 (37)
0.81 (0.57–1.14)
0.88 (0.56–1.39)
Non-productive cough
84/287 (29)
173/435 (40)
0.62 (0.45–0.86)
0.85 (0.56–1.31)
Purulent secretions in nose
14/28 (50)
244/694 (35)
1/84 (0.81–4.17)
0/77 (0.28–2.15)
Headache
a Multiple logistic regression analysis; method: enter; b adjusted for all variables listed in the table; c IAPR = number of encounters with antibiotic
prescription/total number of encounters of GP (analysed encounter not included); d reference is mean prescription rate for all diagnoses.
determined in part by the structure of the health care
system the GP works in, which illustrates the complexity
of prescribing behaviour.2
In conclusion, our results show that to design effective
strategies aimed at rationalizing antibiotic prescribing,
further research into individual prescribing habits
and their determinants could well be more important
than collecting rational arguments based on clinical
evidence.
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